Kai Wai Adult Registration Form

Paddler Information

Name

First Name Last Name

Birth Date

Month Day Year

Gender

Male Female Prefer not to answer

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Home Number

Cell Number

E-mail

example@example.com

Emergency Contact Information

Emergency Contact's Name

First Name Last Name

Relationship

Phone Number

Alt. Phone Number

Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the athlete prescribed an inhaler? If yes, please explain any instructions.

Can you swim

Yes No

Can you tread water for 3 minutes or more?

Yes No

Informed Consent and Acknowledgement

I hereby give my approval for my participation in any and all activities prepared by Kai Wai during the annual membership. In exchange for the acceptance of my candidacy by Kai Wai ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Kai Wai . and all its respective officers, agents, and representatives from any and all liability for injuries to myself arising out of traveling to, participating in, or returning from annual membership and races.

In case of injury to myself, I hereby waive all claims against Kai Wai . including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization

As a named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of myself, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the my life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made.

Permission is also granted to the Kai Wai . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the my admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named athlete (myself).

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Kai Wai North Bay Outrigger Canoe Club Adult Program Registration